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Although law enforcement has been the default behavioral
health crisis responder, the emergency department has been
the default provider. Because most communities do not have
a robust behavioral health crisis continuum, the emergency
department is the go-to place for people with a broad range
of mental health needs, including those who have run out of
medication or do not have anywhere else to turn. But when
they get there, they wait. People wait for urgent psychiatric
care and then wait for continued care, sometimes placed in
an observation room or strapped to a gurney in the hallway.
Wait times in the emergency department can be hours or
days—sometimes weeks or months.
This trend in which people who visit an emergency
department and then wait a long time for treatment,
commonly known in the mental health field as psychiatric
boarding, has drawn nationwide attention because of a
landmark case in Washington State. In 2014, the Washington
State Supreme Court held psychiatric boarding to be
unlawful, ruling that the state’s Involuntary Treatment
Act “does not authorize psychiatric boarding as a method
to avoid overcrowding certified evaluation and treatment
facilities” (30). The Seattle Times reported that people were
detained for days, sometimes months, while bound to
hospital beds parked in emergency department hallways (31).
Usually, they were given medication. Sometimes they were
not. The experience of psychiatric boarding is traumatic, and
the long delays can adversely affect a person’s employment,
finances, personal life, and recovery. During the pandemic,
these trends have worsened because of an increased
proportion of emergency department use for behavioral
health stress (32), especially among children (33).
Box 3 / Special Population: LGBTQ Youth
Rates of distress and suicide attempts are higher
among LGBTQ youth, with rates of suicide attempts
two to four times as high as among other youth. The
Trevor Project (44) is the leading crisis intervention
and suicide prevention organization for young
LGBTQ people up to 24 years old, providing 24/7 text/
chat support (accessed by texting START to 678-678)
and hotline support at 1-866-488-7386.
To foster systemic change, communities must create 911-
988 call center partnerships and develop a feedback loop
between PSAPs and behavioral health crisis services. And
at every potential entry point, first responders must be able
to easily and quickly connect people to treatment. Also,
communities need to build out their behavioral health crisis
continuum—call center hub, mobile crisis services, and crisis
receiving and stabilization facilities—and scaffold robust
and efficient pathways within and between systems, so that
first responders and providers within the system know how
to best connect people to rapid and adequate care—and so
that people in crisis know whom to contact and where to go.
The nationwide 988 designation is not simply an easy-toremember
number to the nation’s mental health, substance
use, and suicide crisis hotline. To solve urgent issues and
emergencies in crisis care, communities must redesign their
crisis systems and turn to evidence-based innovations and
best practices.
How Communities Must Use 988 to Improve Care and Correct Crisis System Disparities 15